USE OF ANTIBIOTIC CEMENT SPACERS/BEADS IN TREATMENT OF MUSCULOSKELETAL INFECTIONS AT A.I.C. KIJABE HOSPITAL

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1 Research article USE OF ANTIBIOTIC CEMENT SPACERS/BEADS IN TREATMENT OF MUSCULOSKELETAL INFECTIONS AT A.I.C. KIJABE HOSPITAL G.C. Mwangi, MBChB, COSECSA Resident Orthopaedics, A.I.C. Kijabe Hospital, P.O. Box -2, Kijabe, Kenya and J.T Macharia, MBChB, MMed (Orthop), FCS Ortho[ECSA], Cure Children s International Hospital, P.O. Box 52, Kijabe 2, Kenya Correspondence to: Dr. G.C. Mwangi, A.I.C. Kijabe Hospital, P.O. Box -2, Kijabe, Kenya chegemwas@yahoo.com ABSTRACT Background: Chronic musculoskeletal infection involving bone present a big challenge to orthopaedic surgeons. These include chronic osteomyelitis, septic non union and open fractures of long bones. Objective: The study was done to determine outcome of treatment of chronic musculoskeletal infections involving bone after use of local antibiotic impregnated cement and report the microbiological patterns of these infections in our hospital. Setting: A.I.C. Kijabe Hospital, Kenya. Patients and methods: The medical charts of all patients treated with antibiotic cement were reviewed over the period of one year [September 12 to September 13]. The cohort consisted of 8% males and % females. The patterns of cultures for infections were reviewed and the procedure of antibiotic impregnated cement placement described. Results: Twenty patients charts were reviewed, 4 (%) were females and 16 (8%) males with ages ranging between 4 years and 62 years. Of these 4% had infected non unions of tibiae and femur, 25% open fractures, 25% chronic osteomyelitis. Culture results revealed 25% mixed infections, % staphylococcus aureus. All patients had initial debridement and antibiotic impregnated bone cement. Infection was cleared in 95% of the patients with 75% having radiological evidence of healing. Forty percent had bone transport of between 4 and 6 cm. A % of the patients had negative cultures at the time of antibiotic cement spacers removal. Conclusions: Use of antibiotic impregnated bone cement could be used in treating chronic musculoskeletal infections. INTRODUCTION Musculoskeletal infections include infected non union, chronic osteomyelitis, and infected Gustillo 3 open fractures. This may also involve bone loss either from initial injury or from debridements (sequestrectomy). Segmental bone defects resulting from traumatic injuries or chronic osteomyelitis are complicated problems with significant long-term morbidity. Historically, due to the difficulty in managing segmental long bone defects, amputation was the preferred treatment. More recently, the use of an antibiotic cement spacer followed by grafting within this space confirmed by an induced biomembrane has been described as a potential treatment strategy (1). In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union. Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection (2,3). Treatment of patients with posttraumatic infected nonunions or highly contaminated open fractures with segmental bone loss of the long bones of the lower extremity is demanding. The use of a 2-stage reconstruction technique, the first stage characterized by thorough debridement, copious lavage, soft tissue coverage, and placement of a cement spacer with antibiotics at the infected site, and the second stage by cement spacer removal, internal fixation, and placement of bone graft with local antibiotics is worth consideration (2). Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts like has been used in some of our patients. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult (4,5). Current data has demonstrated that the use of antibiotic-impregnated cement spacers has improved the outcome of the treatment of infection associated with total joint arthroplasty. These spacers provide direct local delivery of antibiotics while preserving patient mobility and facilitating reimplantation surgery (6). This concept can also be employed in treatment 5 EAOJ; Vol. 9: September 15

2 of musculoskeletal infections and open fractures with bone loss. Ununited fracture of the tibia or femur complicated by infection is not only a complex surgical problem but also a chronic and at times debilitating condition to the patient and therefore a big challenge to the orthopaedic surgeon (7). MATERIALS AND METHODS We retrospectively reviewed charts for patients covering the period from September 12 to September 13. Their ages ranged from 4 years to 62 years. The study included all patients with chronic musculoskeletal infections and open tibia and femur fractures treated with antibiotic impregnated cement spacers or beads at A.I.C. Kijabe Hospital. We excluded patients with musculoskeletal infections or open long bone fractures that were not treated with antibiotic impregnated bone cement. Surgical procedures: During the first stage, the operative extremity was prepared and draped in the usual sterile fashion. The area of bone loss was carefully debrided and irrigated. Debris and nonviable tissues were removed. External fixators were applied after which antibiotic impregnated cement spacers or beads were inserted. Material for cultures and sensitivity was taken for all patients. Each satchet of antibiotic cement was 4 grams and was already impregnated with gentamycin by the manufacturer. Intraoperatively, 2 grams of vancomycin was added to the cement for all the patients. The spacers were left in situ for a period ranging from 6 weeks to 7 months. The definitive procedures that were done after the removal of bone cement included bone transport, bone grafting using the Masquelet technique, intramedullary nails, girdlestone, below knee amputation and knee fusion. RESULTS Of all the patients whose charts were reviewed, four were females and 16 were males with ages ranging between 4 and 62 years. Table 1 Distribution of patients according to their ages Age (years) Total Table 2 Distribution of disease according to the bone affected Disease Bone involved Infected non union Open fractures Infected pseudoarthrosis Chronic osteomyelitis (%) Infected THR 1 5 Total Figure 1 Distribution of disease according to the bone affected Percentage Infected non union Open fractures Infected pseudoarthrosis Chronic osteomyelitis Infected THR EAOJ; Vol. 9: September 15 51

3 Table 3 Bacterial pattern according to type of disease and duration of illness Disease Duration of illness Bacterial pattern Infected non union 3 months to 3 years Pseudomonas aeruginosa, proteus, S. aureus, MRSA Open fractures 1 day to days S. aureus Infected pseudoarthrosis 4 months Negative cultures Chronic osteomyelitis 1 month to 3 years S. aureus, GNR enterobacter clocae, proteus mirabilis Infected total hip replacement 5 months GNR enterobacter clocae, S. aureus Table 4 Results for culture and sensitivity patterns Bacteria Sensitivity Staphylococcus aureus 5 Cefazolin, Chloramphenicol, vancomycin, erythromycin, azithromycin, doxycycline, MRSA 1 Chloramphenicol, tetracycline, cotrimoxazole Pseudomonas aeruginosa 1 Meropenem, ciprofloxacin, septrin Enterobacter clocae 4 Meropenem, ciprofloxacin, ceftriaxone gentamycin, meropenem, tazobacterm *Mixed infection 5 Negative cultures 4 Not taken 1 Total *Mixed infections Proteus mirabilis/ Staphylococcus aureus Enterobacter clocae/ Staphylococcus aureus Staphylococcus aureus/ Proteus mirabilis Eschelichia coli/proteus mirabilis Pseudomonas aeruginosa/ enterobacter clocae P. mirabilis Chloramphenical, meropenem, ciprofloxacin, cefazolin S. aureus Chloramphenicol, Cefazolin E. clocae Meropenem, cefepime, ciprofloxacin S. aureus Erythromycin, chloramphenicol, cefazolin S. aureus Erythromycin, septrin, chloramphenicol, cefazolin P. mirabilis Meropenem, chloramphenicol, ampicillin/sulbactum E. coli Meropenem, chloramphenicol P. mirabilis Ciprofloxacin, meropenem P. aeruginosa Ciprofloxacin, meropenem, septrin E. coli Ciprofloxacin, meropenem, septrin 52 EAOJ; Vol. 9: September 15

4 Table 5 Surgical procedures performed Procedure (%) Debridement Ex fix Antibiotic cement spacer/beads Masquelet technique 5 25 Bone transport 6 IM Nail 3 15 Girdle stone 1 5 BKA 1 5 Knee fusion Figure 2 Surgical procedures performed Table 7 Showing other outcomes Masquelet technique done 17 Knee fusion/ Below knee amputation % Girdle stone resection arthroplasty 1 Bone transport 8 Total 28 Debridement Antibiotic Cement Spacer/beads Bone transport Girdle stone Knee fusion Figure 4 Other outcomes Table 6 Outcomes after removal of antibiotic spacer/beads Outcome Infection cleared/ no further drainage (cultures-negative) Minimal discharge (culture negative) (%) (Cultures negative) Figure 3 Outcomes after removal of antibiotic spacer/beads [Cultures negative] % Infection cleared/no further drainage[cultu res negative] Minimal discharge[cult ure negative] Union Bone transport BKA/Knee fusion Girdlestone The total above for the other outcomes is 28 because all patients who had bone transport done also went to complete bone union. Follow up: Patients were followed up for a period of between 4.5 and 9 months after the last surgical treatment and no reactivation of infection was noted during the period. During this period, negative cultures had been obtained for all the patients under investigation. Of the twenty patients included in the study, 17 of them went to complete bone union with one achieving successful knee fusion, one getting a below knee amputation and one getting a successful girdlestone resection arthroplasty. EAOJ; Vol. 9: September 15 53

5 DISCUSSION Our study revealed high rates of infection clearing (95%), minimal discharge in one patient (5%) and high bone healing (union) rates (9%). The cultures revealed multiple/mixed bacterial infections in single individuals. The long durations of hospital stay was necesitated by culture results with bacterial growths that required prolonged intravenous antibiotic administration. A number of patients presented with chronic discharging sinuses, as late as 3 years and others being referred from other hospitals. Treatment resulted with good results with only one patient having chronic discharge after treatment and with all patients having negative culture results at the time of removal of the antibiotic cement spacers or beads. Vancomycin was added to the bone cement because it is a heat stable antibiotic. Most patients with chronic musculoskeletal infections in our set up would have received gentamycin at some point during their treatment and thus use of vancomycin as the alternative was considered. It is also evident that Masquelet technique is being embraced (25%) in treament of complicated/ chronic infections and bone loss. In the use of Masquelet technique, the cement delivers high-dose local concentrations of antibiotics while filling the dead space. The cement spacer also fills a potential space, induces the formation of a biomembrane, and prevents the involution of the surrounding soft tissue (8). Masquelet and Begue proposed that the membrane prevents graft resorption and improves vascularity and corticalization hence increasing bone union (1). Reconstruction of diaphyseal bone defects due to infections or fractures still represents a major clinical challenge in our set up. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transport technique. Most centres in our set up may lack the capacity to carry out procedures like use of vascularised fibula autograft and thus use of cement implegnated bone cement may be used as an alternative to treat chronic musculoskeletal infections. Limitations in this study include incomplete documentaton for example amount of bone loss intraoperatively. Other factors that would influence healing for example immunosuppresion status for example HIV and albumin levels were not investigated. CONCLUSION Complicated musculoskeletal infection and bone loss after open long bone fractures poses a threat to limbs. Antibiotic spacers are effective and add value in the treament of such infections and bone loss. REFERENCES 1. Tak, M.W., Tak W.L., Xin L., et al. Masquelet technique for treatment of posttraumatic bone defects. The Scien World J. 14; 14: Allende, C. Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity. Tech Hand UP Extrem Surg. ; 14(4): Pelissier, P.H., Masquelet A.C., Bareille R., et al. Induced membrane secrete growth factors including vascular and osteoconductive factors could stimulate bone regeneration. J Orthop Res. 4; 22: Giannoudis, P.V., Faour, O., et al. Masquelet technique for the treatment of bone defects: tipstricks and future directions. 11 Jun;42(6): doi:.16/j.injury Epub 11 May Romana, M.C. and Masquelet, A.C. Vascularized periosteum associated with cancellous bonegraft: an experimental study. Plastic Reconst Surg. 199; 85 (4): Motsitsi, N.S., Masquelet s technique for management of long bone defects: From experiment to clinical application. ISSN East Cent Afr J Surg. 12; 17(2): Quanjun, C., William, M. Mihalko, et al. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. (C) JBJS. 7; 89 (4): Ashok, K.S., Parag, K.S., Salim, K., et al. Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones. Indian J Orthop. 9; 43(4): EAOJ; Vol. 9: September 15